Quick Note: There’s a lot of information here, but I still have more to add. I just wanted to go ahead and get the bulk of it posted.

In 2010 President Obama signed into law the Patient Protection and Affordable Care Act, more commonly referred to as Obamacare. In the three years since, the US has become a veritable utopia not much has happened. Well, in reality a lot has happened, but not much that most people notice yet. In 2014 this changes, as the biggest portions of PPACA will be in effect. In light of the impending slaughter of the elderly at the hands of Obama’s private army, it was suggested that we have a place to discuss PPACA, and pool information and news about its implementation.

Ground Rules

* The thread is about PPACA. As a result it will be natural for there to be some (maybe a lot) of discussion regarding the Washington wheeling and dealing that went on to pass the law. That is fine. This thread is not for debating whether Obama is a right-wing plant trying to sell us out to corporations or a realistic centrist playing Nth dimensional chess against a useless Congress.

* The thread is about PPACA. As a result it will be natural for there to be some (maybe a lot) of discussion about how PPACA compares to Single-Payer and other true UHC systems. That is fine. This thread is not for debating whether we will all die without Medicare For All versus the Free Market saving us all with it’s invisible embrace.

* This thread is about PPACA. If you want to rant about how the American Healthcare system is poo poo and has hosed you over royal, we want to hear about it. In this thread.

* All things PPACA related are fair game. What it did to help you personally, or hurt you. What you like about it; things that are flawed with it. New regulations from the Department of HHS as a result of it. News about your state’s implementation of it (or refusal to implement it). Court challenges to it. Questions about how it will impact you. Promises Obama kept, and those he broke. If it is PPACA related, feel free to post it here.

I will try to update the OP to fix mistakes people find (it’s a huge complex law, I’m sure my summary of it will be lacking), adding interesting news, and useful links.

Obamacare: A Brief History of America’s Wink and a Nod to Socialism

For nearly a century, American politics has had an on-again, off-again relationship with the idea of establishing a system of universal health care. But for a long time, nothing was done about it. In the 60’s Washington got its poo poo together long enough to create Medicare and Medicaid to help the elderly and the horrifically poor. Subsequent years saw changes to both programs, but for the vast majority of Americans, including those who were merely “extremely poor”, there was no help.

In the 1970’s President Nixon proposed reforms to the American Healthcare system that would have established subsidies to assist anyone whose employer did not provide insurance; as well as regulating health insurance to guarantee a minimum level of coverage for everyone. His proposal failed to become legislation. In the 1990’s President Clinton attempted his own reforms. In response to Clinton’s proposal, Republicans pushed for their own proposal. It was based on a 1989 report by the Heritage Foundation, and called for creating a health insurance marketplace to make plans more competitive, offer Americans more choices, assistance for those who had trouble affording it, and a requirement that all Americans buy health insurance. Both Clinton’s and the Republicans’ proposals went nowhere. Then in 2009 Obama began his own push for health care reforms, and after most of a year it was passed into law on March 23rd, 2010. PPACA would provide subsidies for people unable to afford insurance, regulate insurance plans to require minimum levels of coverage, create a marketplace for insurance plans to encourage competition and increase choice, and requires that all Americans purchase health insurance. Obama may have given birth to PPACA, but if so then that bastion of socialist thought, the Heritage Foundation, was the father; and noted Communist sympathizer, Richard Nixon, the grandfather.

PPACA is not the monstrous, unreadable, mountain of paper, legislative nightmare that its opponents made it out to be during the 2009-2010 debates. That being said, it is large and complex. In the following sections I’ve tried my best to explain the important parts. First, starting with a broad overview look at the key components of the law. Then a second section listing some of the good and bad effects of the law. Lastly, a look at more minor changes brought about by the law. For example, an increase in the grant money to nursing students, and programs to help new doctors pay off med school loans. These are not significant enough to be included in the other sections, but still changes people might like to know about. This is by no means to be considered comprehensive. As discussion occurs I can update these sections to fix mistakes and to add new information if it seems important or interesting.

The Core of PPACA

PPACA does a ton of stuff, but I wanted to cover the major, key parts in one place to help people understand the basics of how it works. Since this is just an overview, I’ve tried to keep it succinct. There is more details about how much of this works later on if you wish to know more.

It’s easiest for me to break down the law into five areas: Taxes, Expanded Coverage, The Mandate(s), Regulations, and Medicare.

Taxes

There are a number of revenue sources, big and small, introduced in PPACA to help fund it.

1) Increased the Medicare tax on wealthy (over $200K/$250K) by 0.9%; started in 2013.
2) 10% Tax on Tanning booths, already in effect.
3) Annual Fees on Insurance Companies, and Brand Name drug Manufacturers and Importers.
4) Annual Fees on certain Medical Device manufacturers/importers.
5) Lower limits to how much people can contribute to FSA's, and restricts their usage.
6) 3.8% tax on capital gains; this tax can be applied to certain home sales. There's some limits on this tax though, you have to have an income over $200k and only the gains above $500,000 are taxed. That means if you buy a house for $1M and sell it for $1.4M, no tax. Sell it for $1.6M, and $100,000 of the profit you made is taxed at 3.8%. This tax is a big one for chain emails that scream about everyone having to pay 3.8% of their home's value if they sell it; which is nowhere close to accurate.
7) Tax on certain "Cadillac" plans provided by employers. But this doesn't go into effect until 2018, and to be honest, I wouldn't be surprised to see it stripped out of the law in 2017. It’s very unpopular with labor unions.
8) Fees on people who don't carry insurance (More on that below).

Expanded Coverage

This is the part of the bill that actually helps more people get insurance coverage. Or make the insurance they already have more affordable. It accomplishes this through an expansion of Medicaid and two different types of "Exchanges". Everything in this section begins in 2014.

1) Medicaid is being expanded to cover everyone under a federal poverty level of 133%. However, States are not required to expand coverage, so this may not be an option everywhere as originally envisioned.

2) Individual Insurance Exchanges. These are "virtual marketplaces", run at the State level, where people can pick and choose from a bunch of different insurance plans. These plans are then subsidized by the Federal Government to help make them easily affordable. The poorer you are, the bigger subsidy you get.

3) Small Business Exchanges. These work pretty much the same as above, but are targeted to small businesses buying small group plans for employees. It offers them more options, guaranteed/regulated coverage requirements, and subsidies.

The Mandate(s)

There are actually two Mandates in PPACA, though most people only talk about the first one:

1) Individual Mandate. Starting in 2014, if you don't carry insurance you get fined. Sort of. If you're too poor, there's an exemption. If the cheapest available plan is more than 8% of your income, you’re also exempted. There are exemptions for certain religious groups too; think Amish, not Muslim (loving chain e-mails).

2) Business Mandate. Businesses over a certain size will be mandated to provide insurance or pay a fine per employee beyond the first 50. However, they have another option. The business can give their employee a voucher to use to pick their own plan from the Exchange; if they do this they don't get fined.

Regulations

There's a ton of new regulations; some are in effect already, some start later, some still have to be defined by HHS. Generally they only apply to new plans, including plans that will be in the Exchanges in 2014. Some older plans have been "Grandfathered" in and can avoid the new regulations, though this ends in 2018. Here’s a list of some of the most significant changes:

1) 100% covered (No deductible, co-pay, co-insurance, nothing) preventative care: Vaccines, annual checkups, etc.
2) No more Lifetime or Annual Coverage Maximums.
3) Out of Pocket Maximums capped around $12000 for families, $6000 for individuals in 2014; with a formula to increase slightly each year or so.
4) Can't drop policies of people who get sick.
5) Better claims appeals process
6) Insurance companies must have a 85% or 80% Medical-loss-ratio or higher (varies by type of insurance). If they don't, they have to provide their customers a rebate. Essentially it's saying 85% of the money insurance collects from Premiums has to be spent on medical care. Only 15% is for administration and profit.
7) FSA's, HRA's, and HSA's can't be used for a lot of over-the-counter stuff anymore.
8) 100% coverage for a lot of Women's Services: Contraception, screenings, breast feeding equipment/assistance, domestic abuse, etc.
9) Can't charge different rates for Men vs. Women
10) Can't charge sick people higher rates
11) Can charge different rates based on age, but the difference between the youngest and oldest is limited to 300%. Currently it's not uncommon to see age based costs to differ by 500% to 1000%.

Medicare

Various changes to Medicare include...

1) Reductions in future increases in payments to certain types of hospitals. (This is a big part of that "$700B cut" from Medicare argument thrown around during elections).
2) Reductions in how much the Government pays to private insurance companies for Medicare Advantage plans. (Another big part of the dreaded $700B in “cuts”).
3) Pilot program to pay doctors for curing a patient, rather than paying per service. For example, paying $X for a "broken leg", instead of paying for every individual test, every pain pill, etc. (Another part of the $700B cuts).
4) New payment rules that pay hospitals less if they have bad results (like if they have a lot of patients who end up getting secondary infections while in the hospital), and pay providers a small bonus if they improve. (More of that $700B).
5) An independent advisory board tasked with finding ways to make Medicare more cost effective. This board has taken a lot of flack from Republicans because they think it sounds scary and getting rid of it would be a "legislative win". Ultimately though, the board's recommendations can be blocked by Congress, and they are extremely limited in what they can offer as ideas. It probably won't matter in the long run if the board is disbanded or not because they are likely too restrained to find much savings anyways. (Another, small, part of that $700B).
6) Closed the Medicare Prescription Plan "Donut Hole".
7) Free visits to the doctor to discuss End-Of-Life options, like Hospice care, and Living Wills, with a doctor and family members, once every 5 years. More often if health is deteriorating. (These are Sarah Palin’s dreaded Death Panels).

If you still want more in-depth details about what is changing, then keep reading!

The Good

Medicaid Expansion

Right now Medicaid coverage eligibility varies from state to state; but as an adult who is neither elderly or disabled or pregnant, getting on Medicaid is next to impossible even if you're poor. Most poor families can get their children covered due to CHIP, but not the parents. PPACA changes this, now the whole family will be covered. Anyone under 133% of the Federal Poverty Level will be eligible for Medicaid, even if you’re completely healthy, single, with no kids. The only requirement required will be a measure of income.

Currently, Medicaid funding is split between the Federal Government and the States. Ideally it’s a 50/50 split, realistically it’s more like 60/40. However, the people who will qualify under the new rules will be covered 100% by the Federal Government until 2017. After that, the Federal money will scale back slightly, though they will continue to provide 90% of the funding with no expiration date.

Unfortunately, due to a Supreme Court ruling last year, the states are not required to expand Medicaid. Considering the billions of dollars of Federal money that will enter their state economies, most states are still expected to go ahead with it. Some, like Washington, are even setting the income level higher than 133%. However, other, more spiteful states, like South Carolina, are refusing. I’ll discuss this in more detail later.

This is actually where many, if not most, of the newly covered people will come from; not private insurance.

Medicaid Reimbursement Increases

One problem with Medicaid is that it can be difficult to find doctors who accept it because it often pays out significantly less than Medicare (which usually pays less than Private Insurance plans). The help with that, Medicaid reimbursement rates have been set to match Medicare’s rates. On average, this will increase Medicaid payouts by 73%; though it (like most poo poo in this country) varies wildly from state to state.

The downside? The increase is only for 2013 and 2014. In 2015 all those rates drop back to their original rates. Personally, I think this may have been a budget trick pulled by Democrats to keep the overall cost of PPACA low. After two years of paying Medicare level rates, Congress will likely extend the rates rather than allow Medicaid rates drop by ~50% in 2015 when millions of Americans will be relying on doctors accepting Medicaid. If this cost had been included in the original bill it would have hurt the CBO rating. But it’s possible they’re really just that stupid and think that the temporary increase will get doctors to take Medicaid and then not care when the reimbursements plummet.

Insurance Exchanges

The Exchanges are virtual marketplaces, where many different insurance plans are offered. They all have to provide information about their plans in simple to understand language, with a standardized form so that they can be easily compared side-by-side. Most of this will be on a website, though I suppose there will be other means of selecting a plan for people without internet access. In theory, each state will run their own Exchange, but they’re not required to do so. States that don’t wish to have their own will use one run by the Federal Government instead. Every plan on the Exchange must meet the coverage requirements in PPACA, and the states may set the requirements for plans on their Exchange to be higher if they wish it.

Plans will be rated as either Bronze, Silver, Gold, or Platinum plans. There’s not currently anything that spells out what kinds of plans are at each level, it’s dependant upon the cost sharing of the plan. Plans that take more of the cost burden are rated higher, and will likely have a higher premium. But one way to think about the difference between the ratings is like this:

The subsidies a person or family receive is then based on the second cheapest Silver plan. It is also based on their income compared to the Federal Poverty Level. For example, a young family of four has an income of $59,000 and the second cheapest Silver plan costs around $11,000. Because they make ~250% of the Federal Poverty Level, they are expected to pay 8.05% of their income towards the premium, and the subsidy picks up the rest. As a result they would pay $4600 and the government would pay the remaining $6400. However, if they wanted to they could apply this $6400 subsidy to any other plan on the Exchange. So they could choose the cheapest Bronze plan, apply that $6400 subsidy, and then pay whatever remains. Or pick a more expensive Platinum plan and apply the $6400 to that.

Out of Pocket Subsidies

Less often discussed than the premium subsidies, but related, are subsidies to reduce the Out-of-Pocket costs for low income families. The way this works is that there is a maximum limit for everyone: $6000 individual and $12500 family in 2014. But depending on your income, the government will pick up some of those out-of-pocket costs. So the family of four from the last example would only have an out of pocket maximum of $6250 for the whole family. The government would then pay the other $6250 of out of pocket costs if they occurred.

While the premium subsidies will be paid directly to the insurance providers, it’s currently unclear how these subsidies will work. Or at least I haven’t found an official explanation. Do families have to pay the cost, and get reimbursed? Does the government pay the insurance company to cover the cost? Does the government pay the health care provider in place of the patient?

SHOP Exchanges

These Exchanges are similar to the Exchanges for individuals, but they sell small group insurance plans to small businesses. And the government helps to subsidize these plans as well.

Medicare Advantage Payment Reductions

Medicare Advantage (Medicare Part C) is a program that allows seniors to choose from private insurance plans, rather than using the Federal Medicare plan. The idea behind this is the fallacy that private companies can always provide better results for lower costs than the government. However, the plan also provides a 15% bonus to the insurance companies. So, if the average cost to the government per Medicare recipient is $10,000, the government pays Medicare Advantage plans $11,500. Plus the plans are typically more expensive for the recipients than normal Medicare. So the government pays more, seniors pay more, and insurance companies profit. PPACA eliminates the 15% bonus - Medicare Advantage plans will now be paid the same as it costs to cover the average Medicare recipient for that year.

This is a large chunk of the “Medicare Cuts” Republicans have been bringing up in the past two elections.

Closes Medicare “Donut Hole”

Medicare Part D was introduced during the Bush administration as a way to help seniors pay for prescription drugs. However, it had a weird coverage plan:

PPACA closes the coverage gap. As of this year, Seniors only pay 50% for name brand drugs (79% for generics). This will eventually shrink between now and 2020, at which point they will pay 25%, eliminating the hole completely.

Mandatory Coverage Regulations

All plans will now have to cover a list of conditions and procedures. PPACA itself simply lays out broad categories (like Maternity Care) that they all must cover. The Department of Health and Human Services then decides what falls under each category. There are also limits set on out-of-pocket costs, no annual coverage limits and other regulations. I listed most of them above so I won’t list them all again here. The goal here is to eliminate the problem of millions of Americans being “Underinsured”.

Abolishment of Pre-existing Conditions

This is a pretty significant reform, but doesn’t take much to explain. In 2014, insurance plans cannot deny you coverage based on any health problems you may already have. The one kink in this is that they don’t have to cover anything that occurs in the first 30 days you’re on the plan. So calling up and buying insurance right after you break your legs, but before you go to the hospital isn’t going to do you any immediate good. It will have to cover any follow ups related to the broken legs that occur more than 30 days later, however.

Contraceptive Coverage

Another part of the Mandatory Coverage, but one I felt deserves its own discussion. All plans are now required to cover contraceptives at 100%. There’s not really much more to say here, the benefits of giving nearly all women access to free birth control should be obvious.

Coverage of dependents up to 26 years old

Dependents may now stay on their parents’/guardians’ health insurance plans until they are 26. This has been in effect for a few years now. If you’re under 26, you can remain on your parents plan even if:

- You don’t live with them
- You are married (but spouse/children are not covered)
- You are not financially dependent upon them
- You are eligible for insurance through your employer or school

The only exception for this is certain “Grandfathered” group plans, but this exemption ends in 2014.

State Exchange Waivers

In 2017, the DHHS will begin providing waivers to states who do not wish to run an Exchange or Medicaid. They will be required to have some other state-wide plan in place to provide their residents with healthcare. The most obvious example of this is the state of Vermont which recently passed a law to create a statewide single-payer plan for all residents. In 2017, when they will likely receive the waiver, they will be able to redirect the funds spent on the Exchange and Medicaid to their state’s single payer plan instead.

Business Mandate

Much like the Individual Mandate, there is also a requirement that businesses with more than 50 full time equivalent employees provide them with health insurance. Full time equivalent means that the business takes the number of hours worked by all employees in a month, divides it by 130 (~30 hours a week) and that’s the number of “full time equivalent” employees they have. So simply hiring part time workers does not avoid the mandate, though there are problems with part time workers (discussed further below).

The insurance plan must provide minimum essential coverage defined by PPACA, must provide a minimum value of 60% cost coverage, and the employee’s portion of the premium must be less than 9.5%.

If a business does not provide this, they are taxed. There are two scenarios. In the first, they do not provide any insurance at all. If this happens, the tax is $2000 per full time employee, but the first 30 employees are excluded. The second scenario is where they do provide insurance, but some employees still buy on the Exchanges and get a subsidy. In this case, the tax is $3000 per employee that receives a subsidy, or $2000 per full time employee minus 30 employees; whichever is less.

And these rules apply to non-profits as well as for-profit businesses.

If you’re interested in more details about the Business Mandate, the IRS issued it’s Rules regarding how it interprets this portion of PPACA and you can read them here.

The Not-So-Public Public Options

While the Public Option (a government run plan sold on the Exchanges) did not survive to the final legislation, I am fairly certain a weaker option was included in its place. The DHHS will select two insurance plans which will be made available in all states, one of which must be a non-profit plan.

I am having trouble finding information about this at the moment though, so take this with a grain of salt until I can find more info.

Here is a New York Times article about this part of PPACA. It's actually the Office of Personnel Management that is overseeing these plans, not DHHS. The question now seems to be whether or not these plans were bargained away as part of the tax deal at the start of 2013.

The Bad

Individual Mandate

I’m sure most people have heard about this by now. Starting in 2014, if you do not have health insurance that meets standards set by PPACA you will have to pay a fine/tax. The penalty is assessed per person. So if two family members have insurance, but three don’t the penalty is applied based on three people. In 2014 the penalty is relatively small, but increases in 2015 and 2016:

2014 - $95 per person, up to $285 for a family OR 1% of income -- whichever is higher
2014 - $325 per person, up to $975 for a family OR 2% of income -- whichever is higher
2014 - $695 per person, up to $2085 for a family OR 2.5% of income -- whichever is higher

There is also a fixed cap on the penalty, even for the percentage based penalty. The penalty cannot be higher than the cost of the cheapest Bronze plan available.

Also, the penalty for children under 18 is only half of the amount listed above.

Also, the penalty is applied monthly. So if you have insurance for 7 months, and no insurance for 5 months, you pay 5/12ths of the penalty listed above. And if you are uninsured for 3 months or less, the penalty is waived.

And incase that wasn’t enough to wrap your mind around, there are also several exemptions to the mandate:

- If you make less than 100% FPL.
- If the cheapest plan available is more than 8% of your income after any subsidies you may qualify for. Even if it’s an employer plan.
- Certain religious groups who do not participate in the healthcare system, such as the Amish.
- Also, Native Americans, incarcerated individuals, people visiting on business, and illegal aliens are exempt.

Cadillac Insurance Tax

Starting in 2018 insurance plans that are expensive will be taxed. The tax is 40% of the cost of the plan above the threshold. For individual plans the threshold is $10,200, and $27,500 for family plans. So if a family plan costs $30,000 a year, the tax would be 40% of $2500 -- $1000 in tax. The tax is paid by the insurance provider, not the insured. However, the expectation is for some portion of the cost to be passed to the customer. There are also exemptions for plans for people over 55, and people in high risk professions.

Generally, unions are less than thrilled with this provision. As are big businesses that provide expensive benefits. So I wouldn’t be surprised to see a push to eliminate this in 2017.

Medicare Payment Reductions

To help lower overall costs, and free up money for PPACA, changes were made to some of the formulas for calculating payments that Medicare makes to hospitals and other providers. The change is designed to allow the payments to continue to increase, just at a slower rate than they would have otherwise. The fear here is that it may cause some healthcare providers to decide they don’t want to accept Medicare anymore. However, I also think that we’d see Congress block these reductions if that becomes an issue. But it’s still an area that could end up being bad, or no big deal. Hard to say at this point.

Waivers and Grandfather Plans

Currently things are really confusing because there are all these new regulations to help improve insurance coverage; but at the same time the government is handing out waivers and grandfather exemptions to plans and companies like candy on Halloween. As a result, companies like McDonalds are still giving their employees lovely mini-med plans that come nowhere close to meeting the currently in place regulations. The expectation is that most of these will run out in 2014 or soon after, but it makes it confusing because it means benefits are in place for some people, but not for others.

Preventative Care Becomes Diagnostic Care

PPACA requires that preventative care is covered 100%. However, some of these procedures can suddenly cost money without a patient’s knowledge. For example, a routine colonoscopy at 50 should be covered 100% by insurance. But if the doctor finds something wrong, it ceases to be “preventative” and becomes “diagnostic”, which means the insurance company does not have to cover it 100%.

If you’re healthy, it’s free; if they find bad news, you get to pay for it! Yay!

Single People Pay More Than Families

An oddity of the way subsidies are calculated is that it’s possible for someone to pay more for insurance if they’re alone than if they are paying for an entire family. For example, if you’re single and make $45,000 a year, you may pay up to $4,275 for your own insurance. But a co-worker with a family of four making the same pay would pay $2,672 a year for their entire family.

Great news for families, but really weird and doesn’t seem to make much sense that covering one person costs more than covering a family. In reality, the family plan is more expensive; it’s just that the subsidy for the single person is nearly nonexistent, but for the family it’s about $10,000 a year.

The Ugly

The Obamacare Cliff

This is any issue I haven’t really seen mentioned in the news much; perhaps because it will only affect a small number of people. But it is pretty bad. Like most American social safety nets, Congress stupidly included a hard cap at 400% FPL for benefits, rather than simply allowing benefits to slowly decrease to nothing. For many people this is a non-issue because as they get closer to 400% FPL, their expected insurance costs will be less than the 9.5% required for subsidies.

However, there are people for whom this is not true. The most obvious example are people in their late 50’s to early 60’s who don’t yet qualify for Medicare, live in an expensive area, but make more than 400% FPL ($46,000). For someone in this situation, the expected health insurance plan cost is $12,206 a year; but they don’t qualify for any subsidy. At $46,000 a year, they would receive a subsidy worth $7,800 a year; but if they made an extra $50 for the entire year, the entire subsidy vanishes and they’re left choosing between paying $12000+ for insurance or no coverage.

The good news is that since insurance would cost them more than 25% of their income, they’re exempt from the mandate. Kind of like how getting punched in the face is better than being kicked in the balls.

Optional Medicaid Expansion/People under 100% FPL barred from the Exchanges

In the Supreme Court Case last year, the Supreme Court ruled that the means by which PPACA tried to encourage the states to expand Medicaid was effectively extortion (don’t think they used that term), and illegal. PPACA proposed that they could expand Medicaid, or choose not to expand Medicaid. But if the states did not expand Medicaid, they would lose ALL Medicaid funding. The SCOTUS ruled that the Feds still had to provide the current agreed upon Medicaid funding so long as the state continued to meet the original requirements for that funding.

As a result, some states are choosing to not expand Medicaid; effectively cutting off their nose to spite Obama. But it actually gets worse. For people between 100% FPL and 133%, PPACA allows them to choose either Medicaid or use the Exchanges and pay 2% income with the rest subsidized. So for people in states like South Carolina who are between 100% and 133% FPL, they can still get insurance on the Exchanges. But PPACA expressly states, over and over again, that the Exchanges are for people over 100% FPL. Which means that people who are below that point, but live in states who don’t expand are out of luck. They are excluded from the mandate though. Ball-kick meet face-punch.

Encourages Part-time jobs

While the business mandate requiring that companies share in the expense of providing health insurance for their employees is pretty much a good thing, there is a weird wrinkle in this portion of the law. The rules for calculating whether or not a business is required to provide insurance includes part-time workers. However, the portion of the law that is used to calculate the penalty for not providing insurance does not include part time workers. As a result, a business with 100 part time employees and 25 full time employees is required to provide insurance, but their penalty for not doing so is $0.

Now, you may be wondering what the gently caress they were thinking. I have no idea

Lack of Cost Controls

One of the benefits mentioned earlier was that plans will now have to spend at least 85% (or 80% in some cases) of the money collected from premiums on paying for medical care. This is known as a medical-loss-ratio. Unfortunately, there are very few cost control measures in PPACA. As a result, insurance plans can simply offer to pay providers more money, raise premiums on customers, collect larger revenue, and grow the 15% that they get to keep. In theory the states are supposed to be on guard against this; plans that increase prices too steeply year after year may be removed from the Exchanges. Unfortunately, this relies on having an insurance commissioner with real powers. In some states this is the case, in other states the best you can hope for is a strongly worded letter of disapproval. Similarly, the competition provided by the Exchanges are expected to keep plans from jumping in prices too much. Whether or not this works remains to be seen.

Abortion Bans

There is a clause related to abortion coverage in PPACA. It states that every state’s Exchange must provide at least one plan that does NOT cover abortion. However, there is no related clause which states they must provide at least one plan which does cover abortions. As a result, some states will likely exclude abortion coverage from their Exchanges. This may have legal impacts, but I’m not a legal expert, so I’m not sure what kind of legal challenges individuals could bring against a state that did this.

So I see a lot of this stuff kicks off in 2014. Would that day one of 2014, or what? (I might have missed it if you posted it)

Yes, pretty much everything that starts in 2014 will kick in January 1st, 2014. That being said, the Exchanges should start up around the end of the year so people can start signing up for insurance plans which will then start January 1st, 2014.

Is there parity with medical coverage for all plans now (individual as well as group)?

Are all plans required to offer mental health coverage? If so, what services will be mandated to be covered vs. optional?

Yes, mental health services is one of the broad areas that all plans must now cover. As for the specific services, that's something the Department of Health and Human Services will have to decide. I'm not sure if they've released a list of mental health services yet, I'll see if I can find anything.

edit: So far it looks like they're trying to make the coverage under each area resemble what's offered by good, large-group insurance plans. But I'll keep looking to see if there's a more concrete requirement.

quote:

Will they be able to play games like limiting the number of office visits or requiring pre-authorizations for everything?

This would likely fall under the DHHS regulations; but my guess is that in most cases they'll be able to limit the number of office visits they'll cover and pre-auths are still a thing

[Tell] Is there any groups or congresspersons who are advocating for a more comprehensive UHC such as Medicare for all or something like the rest of the world? Any word on capping insurance profits as a secondary route?

Thank you for such an excellent op. While I understand implementing the PPACA is a huge and complex task, I am curious why no sweetener came into effect immediately given significant Democrat losses in 2012 could've sunk the plan entirely.

3) Pilot program to pay doctors for curing a patient, rather than paying per service. For example, paying $X for a "broken leg", instead of paying for every individual test, every pain pill, etc. (Another part of the $700B cuts).
4) New payment rules that pay hospitals less if they have bad results (like if they have a lot of patients who end up getting secondary infections while in the hospital), and pay providers a small bonus if they improve. (More of that $700B).

It's worth noting a lot of doctors hate this part of PPACA on the well reasoned grounds that it's going to create perverse incentives to avoid all the complex, hard to cure patients like the proverbial plague. Part of the reason the US system is broken on the cost end is that there is an existing perverse incentive to over-test and over-treat patients, so this has to have at least some merit, but on the other hand it's difficult to imagine doctors actively declining to see the guy with pancreatic cancer because of payment statistics. We'll see.

[Tell] Is there any groups or congresspersons who are advocating for a more comprehensive UHC such as Medicare for all or something like the rest of the world? Any word on capping insurance profits as a secondary route?

Yes. The current bill for this is HR 676. It was sponsored by Rep. John Conyers JR, and has 41 co-sponsors. Unfortunately it is unlikely to go anywhere; but such a group does exist.

Thank you for such an excellent op. While I understand implementing the PPACA is a huge and complex task, I am curious why no sweetener came into effect immediately given significant Democrat losses in 2012 could've sunk the plan entirely.

There were, though I don't think I made it clear in the OP. A number of regulations went into effect prior to 2014, some beginning as early as September 2010. Here's a list of some of them off the top of my head:

1) Dependents stay on parents' plan till 26
2) Pre-existing conditions abolished for children under 18
3) 100% Contraceptive coverage (this one started late last year, so there may still be plans without it)
4) Medicare Donut Hole started to close
5) Tax credits to assist small businesses in purchasing insurance
6) Additional funding for state run High Risk Insurance Pools to cover people with pre-existing conditions (I meant to include something about this in the OP, I'll go back and add it)
7) Prohibits lifetime benefit limits

I TAKE BAGS FROM GUILD BANKS TO RESELL ON THE AUCTION HOUSE. I'M A CUNT.

So Medicaid qualification will be income based only? My fiancee and I have a pretty large savings we managed to accrue before, but now we both work pretty menial part time jobs making poo poo money. We should still qualify despite any savings or assets right?

So Medicaid qualification will be income based only? My fiancee and I have a pretty large savings we managed to accrue before, but now we both work pretty menial part time jobs making poo poo money. We should still qualify despite any savings or assets right?

So Medicaid qualification will be income based only? My fiancee and I have a pretty large savings we managed to accrue before, but now we both work pretty menial part time jobs making poo poo money. We should still qualify despite any savings or assets right?

Yes, income qualifications only. But Amused to Death is right, you may not be in a state that is expanding.

However, for two people 100% FPL is $15,510. So if you make more than this you should be able to participate on the Exchanges, even if your state does not expand Medicaid. If you make between $15,510 and $20,600 you guys would be expected to pay 2% of your income ($25-35 a month for both of you), with the government subsidizing the rest. This may actually be a better option than Medicaid depending on your situation.

Does the Medicaid expansion have any mechanism or instruction to the states to make the actual process for applying easier? In my state, it's an absolute nightmare trying to find out if you qualify, and the language is incredibly unclear on the myriad of websites that you need to jump through to even figure out if you qualify.

3) Pilot program to pay doctors for curing a patient, rather than paying per service. For example, paying $X for a "broken leg", instead of paying for every individual test, every pain pill, etc. (Another part of the $700B cuts).
4) New payment rules that pay hospitals less if they have bad results (like if they have a lot of patients who end up getting secondary infections while in the hospital), and pay providers a small bonus if they improve. (More of that $700B).

This seems a bit like NCLB and I hope it doesn't make things worse. I can see the bonus for improving, but if a hospital is genuinely bad due to lack of resources or something and they have issues because of it, fining them won't improve anything. Very conservative logic there, assuming the problem is due to them "not working hard enough" rather than not having enough resources.

"We don't need a toilet. The pile of clothes in the hallway has worked fine for us for years, and it will continue to work."

Thanks for the fantastic OP, solid information without being a billion pages long. As a potentially useful link I'd like to suggest The Council of Insurance Agents & Brokers Health Care Reform FAQ; The Council is an association of insurance administrators and brokers and the FAQs go into a decent amount of detail on a variety of mostly employer questions. For example:

quote:

61. Is the Section 1421 small business tax credit available for tax-exempt small employers?
Yes. There is an explicit provision addressing the manner in which the credit shall apply to such employers.

62. Do we know if an owner is excluded from the average salary calculation and how an employer would actually go about filing for the credit (part of corporate tax return)?
“Owners” are excluded from all of the credit calculation. An "owner" is someone who owns 2% or more of an S Corporation or 5% or more of any other small business. The credit will be part of the corporate tax return.

63. My client's company is a limited liability company (partnership for federal income tax purposes). Do you know how the credit works in this case? Does it flow through to the partners?
We believe it would because partnerships are eligible for the tax credit but we are not tax attorneys so you will have to consult your tax professional for guidance regarding exactly how this will work mechanically.

There's a lot of questions and answers in there both broad and specific that might be a helpful starting point for any posters curious about employer-related aspects and not just us folks on the employee side of the reforms.

It's worth noting a lot of doctors hate this part of PPACA on the well reasoned grounds that it's going to create perverse incentives to avoid all the complex, hard to cure patients like the proverbial plague. Part of the reason the US system is broken on the cost end is that there is an existing perverse incentive to over-test and over-treat patients, so this has to have at least some merit, but on the other hand it's difficult to imagine doctors actively declining to see the guy with pancreatic cancer because of payment statistics. We'll see.

PPACA is a very frequent conversation topic at my med school. Pretty much every physician you talk to has a different opinion on what's going to happen, from "it's a good first step" to "the sky is falling and we're all going to be out of jobs." Part of the reason testing expenses are so high to begin with is due to practicing defensive medicine: covering your rear end by ordering tests to rule out the worst case scenario, not because you believe it's at all likely but because your career would be destroyed if you missed it. Paying per patient is going to strain that practice.

Some of the states participating are surprises (North Dakota, Arizona, Florida, and Michigan are all entirely GOP controlled), but none of the states not participating are that surprising (though blue states with current conservative GOP majorities like Pennsylvania and Wisconsin are on there).

FYI: Virginia expansion is dependent on some ambiguous passage of reform, which was never achieved, so put us down as a "no."

So say a state like Pennsylvania elects a Democratic governor and/or legislature next year. Could they still get in on this?

De Nomolos fucked around with this message at Mar 25, 2013 around 02:55

Some of the states participating are surprises (North Dakota, Arizona, Florida, and Michigan are all entirely GOP controlled), but none of the states not participating are that surprising (though blue states with current conservative GOP majorities like Pennsylvania and Wisconsin are on there).

I actually don't find them that surprising, I'm more shocked at the rest though. I figured most states would buckle after realizing the ACA was here to stay. It's going to leave those states, especially more blue states like Wisconsin and Pennsylvania where the act is more popular in an awkward electoral position since they'll get to campaign on "Every other state got to have their uninsured rate fall numerous points in the course of a few months because of Medicaid, and us? Meh." Plus, the main reason I assume Brewer and such expanded Medicaid even if they don't actually care about helping poor people, that sweet, sweet federal money coming in,

Thanks for the fantastic OP, solid information without being a billion pages long. As a potentially useful link I'd like to suggest The Council of Insurance Agents & Brokers Health Care Reform FAQ; The Council is an association of insurance administrators and brokers and the FAQs go into a decent amount of detail on a variety of mostly employer questions. For example:

There's a lot of questions and answers in there both broad and specific that might be a helpful starting point for any posters curious about employer-related aspects and not just us folks on the employee side of the reforms.

Thanks, this is a great link. I'll add it to the OP tomorrow when I'm not heading to bed.

PPACA is a very frequent conversation topic at my med school. Pretty much every physician you talk to has a different opinion on what's going to happen, from "it's a good first step" to "the sky is falling and we're all going to be out of jobs." Part of the reason testing expenses are so high to begin with is due to practicing defensive medicine: covering your rear end by ordering tests to rule out the worst case scenario, not because you believe it's at all likely but because your career would be destroyed if you missed it. Paying per patient is going to strain that practice.

From what I understand the PPACA is the most comprehensive overhauling of the health care system since probably the 60's at the introduction of Medicare and Medicaid. It's so hideously complex and at the same time far reaching that most experts cannot predict how everything will turn out.

My mom keeps freaking out that due to the Medicare cost controls, hospitals won't want to take Medicare patients, much like they don't want to take Medicaid patients right now. Is there anything to worry about in this regard? I see it's touched on in the OP, but there really isn't any detail, and my aunt works in this sort of field and is constantly telling my mom how Medicare won't be accepted anywhere in a few years.

mastershakeman fucked around with this message at Apr 3, 2013 around 03:41

I think a few things lost some funding during budget battles, but nothing massive or anything. A tax on medical devices I think was repealed(or still in the process), but repealing it has a lot of Democratic support. In a roudnabout way they did in terms of the SCOTUS ruling saying Medicaid expansion was optional.

Does the Medicaid expansion have any mechanism or instruction to the states to make the actual process for applying easier? In my state, it's an absolute nightmare trying to find out if you qualify, and the language is incredibly unclear on the myriad of websites that you need to jump through to even figure out if you qualify.

There will be one application to rule them all.

Every state must accept the Centers for Medicare and Medicaid Services (CMS) application form. It will be available primarily on Healthcare.gov, but also as a printed form. It applies to the Marketplaces, Medicaid, and CHIP.

It's still in draft form and open to public comments. Interestingly enough, the strongest complaint so far is that it is compliant with the motor voter law, and asks if you want to register to vote. I expect CMS has a watchful eye out for a O'Keefe vs. ACORN style sting.

2) Business Mandate. Businesses over a certain size will be mandated to provide insurance or pay a fine per employee beyond the first 50. However, they have another option. The business can give their employee a voucher to use to pick their own plan from the Exchange; if they do this they don't get fined.

This one in specific is one of those incredibly dumb cliffs congress is so fond of. It quite literally places a hiring wall at 99 employees (49?). Huge businesses get good group rate discounts, small startups say 'gently caress healthcare' and pay nothing, so it's a squeeze only on a few specific size businesses.

It'd be much better served with a graduated penalty for not providing insurance. It's honestly the one PPACA argument I can't refute when talking to business owners, because it is just so ineptly implemented.

My mom keeps freaking out that due to the Medicare cost controls, hospitals won't want to take Medicare patients, much like they don't want to take Medicaid patients right now. Is there anything to worry about in this regard? I see it's touched on in the OP, but there really isn't any detail, and my aunt works in this sort of field and is constantly telling my mom how Medicare won't be accepted anywhere in a few years.

It's the other way around. Lots of hospitals in red states are pissed over their governments refusing the Medicaid expansion because it means hundreds of millions they're missing out on.

Medicare/Medicaid will always be accepted until those programs are destroyed. As is non-profit hospitals (which are required by law to accept both programs) make far more money than for-profit ones, largely through overbilling the government, though insurance companies get overbilled as well, and their tax-free status.

I live in the socialist hellhole of Germany, where health insurance is mandatory, and subsidized in many cases. Having dual US-German citizenship, the lovely healthcare in the US is one of the big things that's keeping me from moving back to the 'States, and to me most of this stuff is a huge step in the right direction.

What I would really like to see emerge is a public option, because my experience is that it is one of the only options for providing serious competition on the private market. Anywhere you see things like this fully privatized, prices skyrocket and performance is sub-par, because THE FREE MARKET.

This one in specific is one of those incredibly dumb cliffs congress is so fond of. It quite literally places a hiring wall at 99 employees (49?). Huge businesses get good group rate discounts, small startups say 'gently caress healthcare' and pay nothing, so it's a squeeze only on a few specific size businesses.

It'd be much better served with a graduated penalty for not providing insurance. It's honestly the one PPACA argument I can't refute when talking to business owners, because it is just so ineptly implemented.

There's a work around for that. Those businesses can insure themselves and avoid all those troublesome federal standards. They just need to pay for their employee's health expenses consistent with their state standards for health insurance. Wait, you can't get a good deal on prices? Just contract with your local health insurance company "price club" in Wilmington.

What do you mean you're not incorporated in Delaware? What's wrong with you? It costs like, five bucks. And 45 cents postage.

Anyway, the "price club" will take care of all the administrative hassles and employee health expenses over a few thousand dollars as long as you pay your premiums subscription fees. And the federal government doesn't need to get involved at all.

Every state must accept the Centers for Medicare and Medicaid Services (CMS) application form. It will be available primarily on Healthcare.gov, but also as a printed form. It applies to the Marketplaces, Medicaid, and CHIP.

Stupid Edit: The executive branch no longer calls them Exchanges. They are now Marketplaces.

I have been chomping at the bit to get at exchanges marketplaces since this thing went into law.

I'm currently paying a ridiculous amount for coverage for both my wife and me, since she's unemployed. Like, far more than twice the amount it would cost for both of us to be covered. If she can get her own decent coverage for a lower price, that's going to save us a shitload every month.

This one in specific is one of those incredibly dumb cliffs congress is so fond of. It quite literally places a hiring wall at 99 employees (49?). Huge businesses get good group rate discounts, small startups say 'gently caress healthcare' and pay nothing, so it's a squeeze only on a few specific size businesses.

It'd be much better served with a graduated penalty for not providing insurance. It's honestly the one PPACA argument I can't refute when talking to business owners, because it is just so ineptly implemented.

It is graduated, though there is a bit of a cliff at 50. If you don't provide insurance at all it's $2000 per employee after the first 30. So if you only have full time employees, a 50 employee business will pay $40,000 in penalties ($800 per), but it rises at $2000 per.

I live in the socialist hellhole of Germany, where health insurance is mandatory, and subsidized in many cases. Having dual US-German citizenship, the lovely healthcare in the US is one of the big things that's keeping me from moving back to the 'States, and to me most of this stuff is a huge step in the right direction.

What I would really like to see emerge is a public option, because my experience is that it is one of the only options for providing serious competition on the private market. Anywhere you see things like this fully privatized, prices skyrocket and performance is sub-par, because THE FREE MARKET.

Is it possible to please keep this stuff out of this thread? The everlasting socialized medicine circlejerk is the reason that I don't read the other healthcare thread.

So what are your options once you hit 26? Hope you get a full time job? Or would you be eligible for Medicare?

Exchanges, Medicaid if your income is 133% or below the poverty level(I don't know the exact number, but it's around $15,000 something I think for a single person) and your state has expanded Medicaid, or hope your employer provides insurance. Medicare with exceptions(mainly renal failure I think) is still just for old people.

Exchanges, Medicaid if your income is 133% or below the poverty level(I don't know the exact number, but it's around $15,000 something I think for a single person) and your state has expanded Medicaid, or hope your employer provides insurance. Medicare with exceptions(mainly renal failure I think) is still just for old people.

Technically, it's basically 138% of the poverty level, since the first 5% isn't included when calculating Medicaid eligibility. So if you live in a state where medicaid has been expanded, if you make below ~$16,000 you should qualify for medicaid.

If you live in one where it hasn't expanded, you're probably out of luck depending on your state's rules. If you make at least 100% of the FPL (should be ~$11,700) you can get a subsidy on the exchange. If you don't make enough money for the government to give you money, you're probably stuck with no insurance.